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照護管理 · MEDIUM · SATA

護理師照顧有癲癇病史的病患,哪些措施應包含在癲癇防護中?(選所有適合的)

A nurse is caring for a client with a history of seizures. Which actions should the nurse include in the seizure precautions? (Select all that apply.)

  • AKeep a suction setup at the bedside✓ 正解
    在病床旁備妥抽吸設備
  • BEnsure the bed is in the lowest position✓ 正解
    確保病床處於最低位置
  • CApply padded side rails to the bed✓ 正解
    在床欄上安裝軟墊
  • DPlace a tongue blade in the client's mouth
    將壓舌板放入病人口中
  • EMaintain easy access to oxygen equipment✓ 正解
    保持氧氣設備容易取得
Explanation · 中文詳解

癲癇防護措施旨在預防受傷與維持呼吸道暢通。包括床鋪高度降至最低以防墜床、加裝床欄軟墊、備妥抽痰設備與氧氣以應付呼吸道分泌物及缺氧。切記:現代護理標準絕對禁止將任何物體(如舌壓板)放入痙攣病患口中,以免造成牙齒斷裂或阻塞呼吸道。

Seizure precautions aim to prevent injury and maintain airway patency. They include keeping the bed in the lowest position to prevent falls, padding the side rails, and ensuring suction and oxygen equipment are readily available to manage secretions and hypoxia. Importantly, current nursing standards strictly prohibit placing any object (such as a tongue blade) in the mouth of a seizing client because it can break teeth or obstruct the airway.

✦ 台美臨床差異

台美皆已廢除放置壓舌板的過時做法,但部分資深醫療人員仍有此迷思,護理教育需持續校正。

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